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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> LIST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans&applications as originals will be retained by EHD) <br /> I. Site map enclosed? YES W NO[] <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training <br /> certificates for each person installing or testing any component that is repaired or replaced. Ensure a copy of <br /> the"Site Health and Safety Plan"is available on the jobsite as required by Title 8. <br /> 3. Detailed description of work to he completed. List components to be repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe <br /> how this will be done. (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the UST Installation Application pages 4-8 as necessary for a timely pian review): <br /> On 10/10/2022 Replaced a like for like Defender Series Drop Tube located on Tank 2 87B. <br /> Conducted 201.3 Static Pressure Performance Test and Drop Tube integrity Test. Both <br /> tests passed with no issues found. <br /> 4. List of equipment to be used(Attach manufacturers specification sheets showing third-party approval): <br /> Franklin Fueling Defender Series Drop Tube— PN: EBW708092902 <br /> ❑ntamination Procedures: <br /> a. Wi decontaminated prior to removal? YES [] NO [] <br /> b. Identify contracto ing decontamination: <br /> Name Phone } <br /> Address City Zip <br /> 3of6 <br />